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Suspected Munchausen's Syndrome and Civil Commitment Bradley R. Johnson, MD, and Jessica A. Harrison, MD, PhD j Am Acad Psychiatry Law 28:74-*, 2000 Munchausen's syndrome was named in 1951 by arise that lead to many ethical dilemmas.6Among these Asher1 for the fictional, peripatetic purveyor of tall dilemmas is thepossible need to involuntarily hospital tales, Baron von Munchausen. This syndrome was ize some individuals with the disorder. classified in DSM-IV as factitious disorder with physical symptoms (DSM-IV 300.19). Diagnostic criteria include the intentional production or feign ingofphysical but not psychological symptoms. The motivation for the behavior is to assume the sick role, and external incentives for the behavior, such as eco nomic gain, avoiding legal responsibility, or even malingering, are absent.2 Most states allow emergency commitments for short-term hospitalization until a court hearing is held. Within days to weeks, a formal hearing iscon ducted to decide commitment for hospital-based or outpatient psychiatric care.7 The standards of com mitment in most or all states include, as a result of being mentally ill: danger to others, danger to self, or some disagreement in the literature over the gender distribution ofMunchausen's syndrome, with Eisen- inability to care forself(grave disability). The criteria for being dangerous to self addresses suicidality or severely self-destructive behavior.8 Other require mentsoften includethe immediacy of the harm and thedirect evidence of the threat or attempt. Wexler9 argues that danger to self does not need to be re stricted to suicide but can be broadened in interpre tation to encompass other physical harm. What about individuals who knowingly hurt themselves for unconscious reasons or for secondary gain? Such drath3 stating that female patients equal or exceed is often seen in individuals with factitious disorder. Patients with Munchausen's syndrome utilize many different physicians and hospitals, often trav eling from city to city, state to state, and even to foreign countries. The attainment of hospitalization often becomes the sole focus of such patients' lives. Individuals with this syndrome are frequently young adults whohave work experience in a health care field (nurse, lab technician, ward clerk, etc.). There is the number of males and Sussman4 and Nadelson5 stating that males predominate. Treatment and prognosis of Munchausen cases vary with the patient's need to assume the sick role. Patient resistance to the diagnosis is high, andthese patients are often reluctant to engage in psychiatric treatment even when their behaviors are life-threatening. Situations can It appears that the major diagnoses of candidates for civil commitment are schizophrenia, mania, depres sion, orother psychoses.10 However, Schlesinger etaL11 conclude that, depending onthe local statutes, one may be justified in using anemergency psychiatric commit ment to protect an individual withMunchausen's syn drome from imminent self-harm. Cleveland et al.12 concluded that persons whom psychiatrists consider Dr.Johnson isaffiliated with the Arizona Community Protection and Treatment Center, Phoenix, and Dr. Harrison with the Arizona De partment of Corrections, Florence, AZ. Address correspondence to: Bradley R. Johnson, MD, 2500 East Van Buren St., Phoenix, AZ 85008. 74 highly in need oftreatment may beviewed as meeting the dangerousness criteria for commitment ifthese per sons refuse to voluntarily admitthemselves. We believe this criterion could apply to thefollowing case. The Journal of the American Academy of Psychiatry and the Law Johnson and Harrison Case Report Ms. P was a 42-year-old, divorced, Caucasian fe male who worked as a nurses' aide. She was admitted for evaluation of increasingly frequent firing of her automatic internal cardioverter defibrillator (AICD). Thisdevice had been implanted approximately eight months previously for treatment of her congenital long QT syndrome. This defect in the heart's con duction system had resulted in frequent episodes of ventricular tachycardia, leading to cardiac arrest. A medical workup revealed hypokalemia {K= 2.0 on admission) to bethe mostlikely cause of the frequent AICD firing; however, no organic etiology was ini tially apparent for thehypokalemia. Areview of med ical records revealed a history of suspected diuretic abuse resulting in documented instances of hypoka lemia. Laboratory findings showed evidence of di uretics in Ms. P's system. Despitethis finding, Ms. P adamantly denied past or present use of diuretics. She became hostile and demanded to leave, against medical advice, at the implication of self-induced hypokalemia and its sequelae. Given this problem atic situations, Ms. P's medical team felt that she tion were thought to beconsistent with adiagnosis of a factitious disorder with physical symptoms (DSMIV 300.19). Although Ms. P was not considered to be suicidal, her behavior (diuretic abuse leading to hypokalemia, in turn leading to high risk of acute cardiac arrest) was imminently life-threatening and directly related to her psychiatric diagnosis. On this basis, it was determined that she met the criteria for emergency civil commitment under the danger to selfstandard. Therefore, she was transferred against her will to a county psychiatric hospital for further evaluation and eventual treatment. Discussion Emergency commitment criteria are, in most states, limited to dangerousness to self or others. Rarely is dangerousness to others a factor for Mun chausen's patients, except in the case of Munchaus en's by proxy.13 In this case, criminal charges, rather than civil commitment, are the likely fate of the pa tient. Dangerousness to one's self usually involves suicidal action or intent. Suicidality is conspicuously absent in Munchausen's syndrome. However, the behaviors utilized to feign symptoms and achieve the would be at acute cardiac risk if she were discharged while using diuretics against medical advice. There sick role may at times be life-threatening.14 fore, a psychiatrist was consulted to assist with the factitious disorder have self-injurious behaviors, which could even culminate in death, caused by the desire to become a patient rather than a desire to commitsuicide. He stated that although this typeof behavior could be grounds in some jurisdictions for dismissal of a civil commitment based on danger to self, in some cases the potential for self-destruction is socompelling that it couldwarrant involuntary com mitment. There are only a few cases documented in diagnosis and disposition. Thepsychiatric consultant's review ofMs. P's past medical records produced these additional diagnoses: (1) ulcerative colitis, diagnosed at age 14and leading to colectomy at age 18;(2)Crohn's disease leading to ileostomy; (3) renal insufficiency of unknown etiol ogy; (4) pancreatitis; (5) anemia secondary to renal failure; (6) aspiration pneumonia secondary to meth adone overdose; (7) multiple abdominal complaints Houck15 stated that individuals who suffer from the literature in which individuals were referred for including pain, abscesses, and hemorrhage of un known etiology; and (8) endometriosis. By self-re port, Ms. P had undergone in excess of 20 surgical procedures, which was consistent with the scars ob civil commitment based on complications secondary served on physical examination. Ms. P's psychiatric history was significant for pre scription narcotics and benzodiazepine dependence, prescription forgery, and alcohol abuse. She also had a history of recurrent depressive episodes anda diagnosis of personality disorder NOS, with histrionic and bor McFarland18 proposed thatconsideration should be given toassigning aguardian to take care oftheMun to factitious disorder.15-17 Different ways of dealing with the difficulty of treating a Munchausen's patienthave been proposed. chausen patient. The guardian would then be ableto provide the temporary legal stability that is necessary to gain control of potentially dangerous medical sit uations seen in some Munchausen patients. How derline features. Records indicate one instance ofwrist- ever, cases have been described in which individuals slashing at age 33. Ms. P reported having been a victim of sexual abuse by a paternal uncle. Ms. P's past historyand current clinical presenta with factitious disorders have died secondary to the mental illness from which they suffer.14,19 The key issues are the degree of lethality of these behaviors Volume 28, Number I, 2000 75 Suspected Munchausen's Syndrome and Civil Commitment Manual of Mental Disorders (ed 4). Washington, DC: APA, and the immediacy of the threat to life. We contend that in these situations, involuntary civil commit ment ofa Munchausen patient is not only therapeu ticbut may be necessary to save a life. This was felt to be the situation in the case of Ms. P. Although treatingan individual who suffers from factitious disorder is likely to be difficult, there areat least a few documented cases of successful treatment when under commitment.16,17 Obviously, clini cians will not utilize this approach lightly. They must have sufficient evidence from current and past hos pitalization reports to supportthediagnosis of Mun chausen's syndrome. Moreover, the benefit of invol untary commitment, in terms of ensured patient 1994, p 474 3. Eisendrath S): Factitious disorders, in Review of General Psychi atry (ed 2). Edited by Goldman HH, Englewood Cliffs, NJ: Appleton & Lange, 1988,pp 470-6 4. Sussman N: Factitious disorders, in Comprehensive Textbook of Psychiatry (ed 5). Edited by Kaplan HI, Sadock BT: Baltimore: Williams and Wilkins, 1989 5. Nadelson T: The Munchausen's spectrum—borderline charac teristic features. Gen Hosp Psychiatry 1:11-17,1979 6. Ford CV, Abernathy V: Factitious illness: a multidisciplinary con sideration ofethical issues. GenHosp Psychiatry 3:329-36,1981 7. Miller RD:An update on involuntary civil commitment to out patienttreatment.HospCommunity Psychiatry 43:79-81,1992 8 Appelbaum PS, Gutheil TG: Clinical Handbook of Psychiatry and the Law (ed2). Baltimore: Williams andWilkins, 1991, pp 9. Wexler DB: Mental Health Law. New York: Plenum Press, 1981, pp 11-57 35-80 safety, must outweigh the suspension of a patient's civil liberties. Again, this appeared to be the case for the person presented in this paper. Therefore, the risk-benefit ratio of involuntary commitment must be carefully weighed on a case-by-case basis. 10 11 Schlesinger R, DanielDG, Robin V,etab. Factitious disorderwith physical manifestations: pitfalls of diagnosis and management. South Med J 82:210-14, 1989 12 Conclusion Individuals who suffer from Munchausen's syn drome sometimes engage in life-threatening behaviors. Hiday VA: Civil commitment: a review of empirical research. Behav Sci Law 6:15-43, 1988 Cleveland S,Mulvey EP, Appelbaum RS, Lidz CW: Do dangerousness-oriented commitment laws restrict hospitalization of pa tients whoneed treatment?—a test. HospCommunity Psychiatry 40:266-71, 1989 13 Manthei DJ, Pierce RL, Rothbaum RJ, Manthei U, Keating JP: Munchausen's syndrome by proxy: covertchild abuse. J Fam Vi It is important to consider the means by which these olence 3:131-40, 1988 Nichols GR, Davis GJ, CoveyTS: In the shadowof the baron: individuals could be adequately and successfully treated. Involuntary commitment may be theonly sav ing modality in severe cases. Because of the dearth of literature about this concept, we recommend that fur 14 15 HouckCA: Medicolegal aspects of factitious disorder. Psychiatr ther research be done on the outcome ofcivil commit ment for individuals with factitious disorders. The eth ical dilemmas associated with civil commitment of 16. Miller RD, Blancke FW, Doren DM, Maier GJ: The Mun chausen patient in a forensic facility. Psychiatr Q 57:72-6, 1985 Yassa R:Munchausen's syndrome: a successfully treatedcase. Psy- these patients also require further comment. 18 McFarland BH,Resnick M, Bloom J: Ensuring continuity ofcare fora Munchausen patient through a public guardian. Hosp Com 19. 1. Asher R: Munchausen's syndrome. Lancet 1:339-41, 1951 Sutherland AJ, Rodin GM: Factitious disorders in a general hos pital setting: clinical features and a review of the literature. Psy- 2. American Psychiatric Association: Diagnostic and Statistical chosomatics 31:392-9, 1990 8:216-19, 1990 Med 10:105-16,1992 17 chosomatics 19:242-3, 1978 munity Psychiatry 34:65-6, 1983 References 76 sudden death dueto Munchausen's syndrome. Am J Emcrg Med The Journal of the American Academy of Psychiatry and the Law